Cardiorenal and Metabolic Convergence in Acute Heart Failure: Severe Cardiorenometabolic Syndrome as a High-Risk Phenotype

Background. Cardiorenometabolic syndrome (CRMS) reflects the interaction between heart failure (HF), chronic kidney disease, and metabolic disorders. Its prognostic impact during the acute phase of HF remains poorly defined. The primary objective of this study was to assess whether severe CRMS (sCRMS: estimated glomerular filtration rate < 45 mL/min/1.73 m² associated with type 2 diabetes mellitus and/or obesity) predicts worse clinical outcomes. Methods. Retrospective observational study of a prospective cohort including 2,228 patients admitted for acute HF between 2015 and 2025. Clinical characteristics and outcomes (mortality, HF readmission, and the composite endpoint) were compared between patients with and without sCRMS. Results. sCRMS was present in 486 patients (21,8%) who were older, had worse functional class, and a higher burden of cardiovascular comorbidities. They presented more frequently with systemic congestion and less often with de novo HF. During follow-up, sCRMS was associated with higher mortality (29.4% vs 18.4%), HF readmissions (56.2% vs 33.5%), and the composite endpoint (85.6% vs 51.9%) (all p< 0.001). In multivariable analysis, sCRMS remained an independent predictor of mortality (HR 1.25), readmissions (HR 1.24), and overall morbidity and mortality (HR 1.20). Conclusions. In patients hospitalized for acute HF, sCRMS consistently identified a high-risk clinical phenotype with an unfavorable prognosis. These findings support the value of sCRMS as a simple and reproducible prognostic marker and highlight the need for integrated cardiorenometabolic strategies during post-discharge follow-up.